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Florida Proof Loss Form in PDF

The Florida Proof of Loss form is a legal document used to formally report a loss to an insurance company. This form serves as a sworn statement, detailing the specifics of the loss and the claimant's interest in the property. Accurate completion of this form is crucial, as it can affect the outcome of an insurance claim.

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The Florida Proof of Loss form is a critical document for anyone filing an insurance claim related to property damage. This form serves as a formal declaration to the insurance company, detailing the specifics of the loss and the insured's interest in the property. It requires the claimant to provide essential information, including the amount of the insurance policy at the time of the loss, the date and time of the incident, and the cause of the loss. Additionally, the form prompts the insured to disclose any other policies that might cover the loss and to identify any mortgages or lienholders associated with the property. The claimant must also outline the total insurance amount, the actual cash value of the property at the time of loss, and a breakdown of the damages incurred. To ensure the integrity of the claim, the form includes a sworn statement, affirming that all provided information is accurate and truthful. Importantly, it highlights the legal ramifications of submitting false information, which can result in serious penalties under Florida law. Understanding the nuances of this form is essential for policyholders seeking to navigate the claims process effectively and ensure they receive the compensation they are entitled to.

Form Example

SWORN STATEMENT IN PROOF OF LOSS

PURSUANT TO S. 817. 234, FLORIDA STATUTES, ANY PERSON WHO, WITH THE INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER OR INSURED, PREPARES, PRESENTS, OR CAUSES TO BE PRESENTED A PROOF OF LOSS OR ESTIMATE OF COST OR REPAIR OF DAMAGED PROPERTY IN SUPPORT OF A CLAIM UNDER AN INSURANCE POLICY KNOWING THAT THE PROOF OF LOSS OR ESTIMATE OF CLAIM OR REPAIRS CONTAINS ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION CONCERNING ANY FACT OR THING MATERIAL TO THE CLAIM COMMITS A FELONY OF THE THIRD DEGREE, PUNISHABLE AS PROVIDED IN S. 775.082, S.775.803, OR S.775.084, FLORIDA STATUTES.

$__________________________________________		________________________________________________
AMOUNT OF POLICY AT TIME OF LOSS		POLICY NUMBER
___________________ _______________________		________________________________________________
DATE ISSUED	DATE EXPIRES	AGENT

1.Name of Insurance Company:____________________________________________________________________________

2.	Claim Number: ___________________________	3.	Named Insured(s)______________________________
4.	Date of Loss: _____________________________	5.	Time of Loss: _________________________[a.m./ p.m]

6.Cause of Loss: The cause and origin of the said loss were:______________________________________________________

________________________________________________________________________________________________________

7.Title and Interest: [My/Our] Interest in the property involved at the time of loss was as follows: ____________________

_____________________________________________________________________________________________

8.Names of Mortgages/Lienholders :________________________________________________________________________

________________________________________________________________________________________________________

Other than the insureds and any and all loss payees indicated in the policy of insurance, there are no other persons who have an interest or lien in the property involved, except for above named mortgage or lienholders, except:

________________________________________________________________________________________________________

9.Other policies of insurance which may cover the loss: ________________________________________________________

10.Describe changes in title to the property during the policy term or changes in occupancy of property during policy

term:___________________________________________________________________________________________________

11.Total Insurance: The Total amount of insurance upon the property described by this policy was, at the time of loss $__________________________, as more particularly specified in the policy declarations sheet.

12.The Actual Cash Value of said property at the time of loss was: $_______________________________________________

13.Loss and Damage: The specifications of damaged buildings, if applicable, are contained in the attachments hereto; The specifications of damaged contents, if applicable, are contained in the attachments hereto; If applicable, ALE or rental loss receipts are attached hereto. The loss and damage is as follows:

Building:	$________________________
Other Structure(s)	$________________________
Contents	$________________________
Adjusted Living Expenses ("ALE")	$________________________
The Whole Loss Total:	$________________________
Deductible:	$________________________
Whole Amount Claimed Minus Deductible		$________________________

The loss did not originate by any act, design, or procurement on your part; no property has been concealed, and no attempt to deceive the said company as to the extent of the loss has been made. The undersigned certify that the statements and information contained herein with respect to the loss reported are accurate and truthful to the best of [his/her/their] knowledge and belief.

_________________________________________	____________________________________________
Signature of Insured	Signature of Insured
Print Name:______________________________________	Print Name ___________________________________

State of Florida, County of ______________

Sworn to and subscribed to before me on this ________ day of ____________________________________ , 20 _______ .

	Personally known, or
Notary Public, State of Florida_________________________	Produced :_____________________________________

⇩ Florida Proof Loss File

Document Breakdown

Fact Name	Description
Governing Law	This form is governed by Florida Statutes, specifically S. 817.234.
Intent to Defraud	Submitting false information with the intent to deceive an insurer is a felony.
Policy Information	The form requires details such as the policy number and amount at the time of loss.
Date and Time of Loss	Claimants must provide both the date and time of the loss incident.
Cause of Loss	The form asks for a detailed description of how the loss occurred.
Interest in Property	Claimants must state their interest in the property at the time of the loss.
Additional Insurance Policies	Any other insurance policies covering the loss must be disclosed.
Certification	The form must be signed by the insured, affirming the truthfulness of the information provided.

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